Texas Mental Health Intake & Evaluation Form
Patient Name: Mikayla
Medical Record #: 2158
Date of Birth:
Current Age: 8 years old
Date Service Provided: December 20, XXXX
Primary Care Provider: Medicaid
Reason for Referral:
Mikayla was referred to the agency by her school counselor and her classroom teacher as well.
However, Mikayla has been showing behavioral issues at school frequently. Besides, Mikayla
appears to struggle to follow directions, stay on task, remain seated, and has low grades. Mikayla
was retained in second grade, and her recent teacher consulted with her previous teachers
(kindergarten and first grade). They have expressed that they do not think that Mikayla has
communication issues or special learning disorder because she performed her academic skills
above the grade-level expectations in small and one-on-one attention. Now is in a large
classroom where Mikayla is in constant motion, yelling when she should be talking quietly and
easily distracted. Mikayla was alluded to the school counselor today in the classroom because
she braked the fish tank during the silent reading activity. Mikayla stated, “I was just trying to
feed Flipper.”
Service(s) provided:
Evaluation Procedures:
☒Interview with
☒Review of records
☒Psychological testing: Environmental Assessment
Behavioral Assessment
Background Information
Medical History: N/A
☐ see medical chart for ☐ diabetes ☐ per patient history is significant for chronic
details ☐ sleep pain
☐ addiction disorder ☐ nutrition/obesity/eating disorder
☐ cardiac illness ☐ fertility ☐ other
☐ hypertension issues
Additional Comments: Mikayla’s mom describes her as “handful”, but very sweet
1
, Current Medications per patient: N/A
Current Functioning
Orientation:
Appearance/Personal Hygiene:
Eye Contact:
Psychosis:
Hallucinations: ☒None ☐Auditory ☐visual ☐olfactory ☐gustatory
Delusions: ☐Bizarre ☐Grandiose ☐Jealousy ☐Nihilistic ☐Persecutory ☐Reference
☐ Somatic
Homicidal Ideation/Intentions:
☐ Duty to Protect process completed
Insight:
Intelligence:
Memory/Cognition:
Mood/Affect:
☐ Angry ☐ Expressing Guilt ☐ Suspicious
☐ Anxious ☐ Hopeful ☐ Tearful
☐ Appropriate ☐ Being Irritable ☐ Having Trouble
☐ Bright ☐ Labile Concentrating
☐ Distressed ☒No follow directions ☐ Withdrawn
☐ Fatigued ☒Lack of focus ☐ Expressing
☐ Flat Worthlessness
☐ Expressing Worry
Suicidal Ideation/Intentions:
Frequency of occurrence: N/A
How long does it last: N/A
Intensity of suicidal thoughts: N/A
Reasons individual would rather die than live: N/A
Detailed Plan:
Plan location: N/A
How lethal is the method: N/A
Access to lethal methods: N/A
If firearms, are they being removed from patient access:
2
Patient Name: Mikayla
Medical Record #: 2158
Date of Birth:
Current Age: 8 years old
Date Service Provided: December 20, XXXX
Primary Care Provider: Medicaid
Reason for Referral:
Mikayla was referred to the agency by her school counselor and her classroom teacher as well.
However, Mikayla has been showing behavioral issues at school frequently. Besides, Mikayla
appears to struggle to follow directions, stay on task, remain seated, and has low grades. Mikayla
was retained in second grade, and her recent teacher consulted with her previous teachers
(kindergarten and first grade). They have expressed that they do not think that Mikayla has
communication issues or special learning disorder because she performed her academic skills
above the grade-level expectations in small and one-on-one attention. Now is in a large
classroom where Mikayla is in constant motion, yelling when she should be talking quietly and
easily distracted. Mikayla was alluded to the school counselor today in the classroom because
she braked the fish tank during the silent reading activity. Mikayla stated, “I was just trying to
feed Flipper.”
Service(s) provided:
Evaluation Procedures:
☒Interview with
☒Review of records
☒Psychological testing: Environmental Assessment
Behavioral Assessment
Background Information
Medical History: N/A
☐ see medical chart for ☐ diabetes ☐ per patient history is significant for chronic
details ☐ sleep pain
☐ addiction disorder ☐ nutrition/obesity/eating disorder
☐ cardiac illness ☐ fertility ☐ other
☐ hypertension issues
Additional Comments: Mikayla’s mom describes her as “handful”, but very sweet
1
, Current Medications per patient: N/A
Current Functioning
Orientation:
Appearance/Personal Hygiene:
Eye Contact:
Psychosis:
Hallucinations: ☒None ☐Auditory ☐visual ☐olfactory ☐gustatory
Delusions: ☐Bizarre ☐Grandiose ☐Jealousy ☐Nihilistic ☐Persecutory ☐Reference
☐ Somatic
Homicidal Ideation/Intentions:
☐ Duty to Protect process completed
Insight:
Intelligence:
Memory/Cognition:
Mood/Affect:
☐ Angry ☐ Expressing Guilt ☐ Suspicious
☐ Anxious ☐ Hopeful ☐ Tearful
☐ Appropriate ☐ Being Irritable ☐ Having Trouble
☐ Bright ☐ Labile Concentrating
☐ Distressed ☒No follow directions ☐ Withdrawn
☐ Fatigued ☒Lack of focus ☐ Expressing
☐ Flat Worthlessness
☐ Expressing Worry
Suicidal Ideation/Intentions:
Frequency of occurrence: N/A
How long does it last: N/A
Intensity of suicidal thoughts: N/A
Reasons individual would rather die than live: N/A
Detailed Plan:
Plan location: N/A
How lethal is the method: N/A
Access to lethal methods: N/A
If firearms, are they being removed from patient access:
2
